Citation Nr: 1518775 Decision Date: 05/01/15 Archive Date: 05/13/15 DOCKET NO. 11-02 086 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Denver, Colorado THE ISSUES 1. Entitlement to an initial evaluation in excess of 50 percent for posttraumatic stress disorder (PTSD). 2. Entitlement to service connection for obstructive sleep apnea (OSA), to include as secondary to PTSD. 3. Entitlement to service connection for a left knee disability, to include degenerative joint disease. 4. Entitlement to service connection for a right knee disability, to include focal calcification of the medial joint line and degenerative joint disease. 5. Entitlement to service connection for a right hand and finger disability, to include osteoarthritis. 6. Entitlement to service connection for bilateral ankle sprains. 7. Entitlement to service connection for a bilateral elbow disability. 8. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities. REPRESENTATION Appellant represented by: Colorado Division of Veterans Affairs ATTORNEY FOR THE BOARD J. Turner, Associate Counsel INTRODUCTION The Veteran served on active duty from December 1965 to November 1967. These matters come before the Board of Veterans' Appeals (Board) on appeal from a January 2010 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Denver, Colorado. The issues of entitlement to service connection for OSA and entitlement to a TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. Prior to August 11, 2014 and since October 1, 2014, the clinical signs and symptoms associated with the Veteran's PTSD more nearly approximate occupational and social impairment with reduced reliability and productivity. 2. The Veteran does not have a current diagnosis of a right elbow disability. 3. The preponderance of the evidence is against a finding that the Veteran's left knee disability had its onset in service or that it is otherwise associated with service. 4. The preponderance of the evidence is against a finding that the Veteran's right knee disability had its onset in service or that it is otherwise associated with service. 5. The preponderance of the evidence is against a finding that the Veteran's right hand and finger disability had its onset in service or that it is otherwise associated with service. 6. The preponderance of the evidence is against a finding that the Veteran's bilateral ankle sprains disability had its onset in service or that it is otherwise associated with service. 7. The preponderance of the evidence is against a finding that the Veteran's bilateral elbow disability had its onset in service or that it is otherwise associated with service. CONCLUSIONS OF LAW 1. Prior to August 11, 2014 and since October 1, 2014, the criteria for an initial rating in excess of 50 percent for PTSD are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.21, 4.125, 4.130, Diagnostic Code 9411 (2014). 2. The criteria for service connection for a right elbow disability have not been met. 38 U.S.C.A. §§ 1110, 1154 (West 2014); 38 C.F.R. §§ 3.159, 3.303 (2014). 3. A left knee disability was not present in service or manifested for many years thereafter, and is not shown to be otherwise related to service. 38 U.S.C.A. §§ 1110, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.303 (2014). 4. A right knee disability was not present in service or manifested for many years thereafter, and is not shown to be otherwise related to service. 38 U.S.C.A. §§ 1110, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.303 (2014). 5. A right hand and finger disability was not present in service or manifested for many years thereafter, and is not shown to be otherwise related to service. 38 U.S.C.A. §§ 1110, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.303 (2014). 6. The criteria for service connection for bilateral ankle sprains have not been met. 38 U.S.C.A. §§ 1110, 1154 (West 2014); 38 C.F.R. §§ 3.159, 3.303 (2014). 7. The criteria for service connection for a bilateral elbow disability have not been met. 38 U.S.C.A. §§ 1110, 1154 (West 2014); 38 C.F.R. §§ 3.159, 3.303 (2014). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist VA has met all statutory and regulatory notice and duty to assist provisions as to the Veteran's claims for entitlement to service connection for a bilateral elbow, bilateral knee, bilateral ankle, and right hand and finger disability, and claim for a higher initial evaluation for PTSD. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2014). A. Duty to Notify When VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and his representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. Compliance with the first element requires notice of the five service connection elements: (1) veteran status; (2) existence of a disability; (3) a connection between the veteran's service and the disability; (4) degree of disability; and (5) effective date. See 38 U.S.C.A. § 5103(a); see also Dingess v. Nicholson, 19 Vet. App. 473, 490 (2006). The initial rating appeal arises from a granted claim of service connection. Compliance with the first notice element requires notice of the five service connection elements in initial ratings cases: (1) veteran status; (2) existence of a disability; (3) a connection between the veteran's service and the disability; (4) degree of disability; and (5) effective date. See Dunlap v. Nicholson, 21 Vet. App. 112 (2006). A September 2009 letter fully satisfied the duty to notify provisions prior to initial adjudication of the Veteran's claims in January 2010. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). B. Duty to Assist The Board also concludes VA's duty to assist in obtaining records has been satisfied. The Veteran's service treatment records (STRs) and VA medical records are in the file. Private medical records identified by the Veteran have been obtained, to the extent possible. The Veteran has at no time referenced outstanding records that he wanted VA to obtain or that he felt were relevant to the claims. The duty to assist also includes providing a medical examination or obtaining a medical opinion when such is necessary to make a decision on the claim, as defined by law. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c); McLendon v. Nicholson, 20 Vet. App. 79, 81-82 (2006). If VA provides a claimant with an examination in a service connection claim, the examination must be adequate. Mitchell v. Shinseki, 25 Vet. App. 32, 43 (2011). The probative value of a medical opinion is derived from a factually accurate, fully articulated, and soundly reasoned opinion. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 300 (2008). The Veteran was afforded an April 2014 medical examination to obtain an opinion as to whether his bilateral elbow, bilateral knee, bilateral ankle, and right hand and finger disabilities were the result of military service. This opinion was rendered by a medical professional following a thorough examination and interview of the Veteran and review of the claims file. The examiner obtained an accurate history and listened to the Veteran's assertions. The examiner laid a factual foundation and reasoned basis for the conclusions that were reached. Therefore, the Board finds that the examination is adequate. See Nieves-Rodriguez, 22 Vet. App. at 300. The RO also provided the Veteran appropriate VA examinations in October 2009 and November 2012 to assess the severity of his PTSD. The Veteran has not reported receiving any recent treatment specifically for this condition (other than at VA and the private treatment mentioned above, records of which are in the file), and there are no records suggesting an increase in disability has occurred as compared to the prior VA examination findings. There is no objective evidence indicating that there has been a material change in the severity of the Veteran's service-connected PTSD since he was last examined. 38 C.F.R. § 3.327(a). The examination reports provide sufficient evidence to apply the ratings schedule and to determine that the schedular rating is adequate to rate the disability. The duty to assist does not require that a claim be remanded solely because of the passage of time since an otherwise adequate VA examination was conducted. See Palczewski v. Nicholson, 21 Vet. App. 174, 182 (2007) (mere passage of time does not require VA to provide a new medical examination); see also VAOPGCPREC 11-95. The VA examination reports are thorough and supported by VA outpatient treatment records. The examinations in this case are an adequate basis on which to adjudicate the claim. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Newhouse v. Nicholson, 497 F.3d 1298 (Fed. Cir. 2007). II. Service Connection The Veteran contends he is entitled to service connection for a bilateral knee disability, a right hand and finger disability, a bilateral ankle disability, and a bilateral elbow disability, all of which he asserts began in service. For the reasons that follow, the Board finds that these disabilities are not related to service. As such, service connection for these disabilities is not warranted. Service connection is warranted where the evidence of record establishes that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated thereby. 38 U.S.C.A. 1110, 1131 (West 2014); 38 C.F.R. 3.303(a) (2014). Service connection may be established for a disability resulting from disease or injury incurred by active service. 38 U.S.C.A. § 1110, 1131; 38 C.F.R. § 3.303(a). To establish entitlement to service-connected compensation benefits, a Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred during service. Shedden v. Prinicipi, 381 F.3d 1163, 1167 (Fed. Cir 2004). Service connection may also be granted for chronic disabilities if such are shown to have been manifested to a compensable degree within one year after the Veteran was separated from service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. As an alternative to the nexus requirement, service connection for these chronic disabilities may be established through a showing of continuity of symptomatology since service. 38 C.F.R. § 3.303(b) (2014). The option of establishing service connection through a demonstration of continuity of symptomatology rather than through a finding of nexus is specifically limited to the chronic disabilities listed in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) (rejecting the argument that continuity of symptomatology in § 3.303(b) has any role other than to afford an alternative route to service connection for specific chronic diseases). However, ankle sprains and elbow sprains are not included in the listed disease under § 3.309, and therefore service connection is not available under § 3.303(b) for those disabilities. Regardless of the theory of entitlement, service connection requires the existence of a current disability. See Degmetich v. Brown, 104 F.3d 1328 (Fed. Cir. 1997). The Veteran's STRs show that at both his entrance and separation examinations, conducted in November 1965 and November 1967 respectively, the Veteran's upper and lower extremities were noted as normal, without indication of any injury to the knees, elbows, ankles, or right hand and fingers. The accompanying Report of Medical History, reveals the Veteran denied experiencing swollen or painful joints, painful or trick elbows, trick or locked knee, or foot trouble. The STRs are silent as to any treatment for injury during service. Private treatment records dated May 2003 indicate the Veteran complained of a catch in his right knee after getting up and down a number of times at work. The Veteran denied prior history of knee injury, but x-ray showed old calcification along the medial posterior aspect of the joint line. The report assessment listed a medial meniscal injury. In August 2009, the Veteran submitted a claim for severe and chronic pain in his bilateral elbows, bilateral ankles, bilateral knees, and right hand and fingers. A February 2010 VA treatment record reveals the Veteran presented requesting that his finger be checked. The Veteran complained of swelling of the 4th finger on his right hand, reporting that the day of examination, his finger was discolored. Examination revealed a swollen, red and bruised, but non-tender finger. The Veteran reported he could not recall injuring his hand. X-ray results suggested osteoarthritis, and findings that may be seen in hyperparathyroidism. In a private treatment record dated June 2012, Dr. T.G. stated that the Veteran had been a patient since 2012, and was treated for a number of conditions, including instability of the right knee, residuals of a fracture of femur, and ligament tear and right hip condition. Dr. T.G. noted that the Veteran had degenerative arthritis of the right knee, and a remote ligamentous tear of the right knee, which was part of his condition of instability of the right knee. Dr. T.G. also stated "As the result of the progression of these conditions that have occurred as a result of the service related conditions/injuries, the Veteran has developed increased disability." September 2012 VA treatment records show the Veteran underwent surgery for the total left knee replacement. At an April 2014 VA examination, the Veteran stated that quite a few years earlier, he developed a little soreness in his ankles, and noted that his ankles also swelled all the time, but he had not sought treatment and denied trauma. X-ray results revealed no acute abnormality in either ankle, but the findings were suggestive of an old bilateral ankle sprain and atherosclerotic disease. The examiner diagnosed old bilateral ankle sprains. Regarding his elbows, the Veteran stated that a number of years ago, he noted stiffness and soreness of the elbows. He stated that the naproxen he took for wrist pain helped with the symptoms, though the pain was mostly constant. He denied any trauma to his elbows. X-ray results for the elbows showed no significant abnormality in either elbow. The examiner diagnosed mild left elbow strain, but stated the right elbow was normal on examination and x-ray, and provided no diagnosis. With respect to his knees, the Veteran stated that years ago, after service, he developed pain in the left knee. He noted that he had injured the left knee in service, but never saw anyone for it. The report notes the Veteran was seen for this in later years, and had the left knee replaced in September 2012 due to degenerative joint disease. The Veteran stated the right knee had hurt for years, as well, but denied trauma to the right knee. The Veteran noted the left knee was much improved after surgery, but that he still experienced pain in the right knee most of the time. The examiner diagnosed right knee focal calcification of the medial joint line as of the date of examination, noted a 2012 diagnosis of degenerative joint disease of the left knee. Regarding his right hand and fingers, the Veteran stated that he noted pain and stiffness, worst in his thumb15 to 20 years earlier. He denied receiving treatment for this, or experiencing any trauma to his hand. He reported his pain was present most of the time. The examiner diagnosed degenerative joint disease of the right hand, based on x-ray results showing findings of osteoarthrosis of the distal interphalangeal joints, second and third metacarpal joints, and to a lesser degree, in the first carpometacarpal joint. At the time of examination, the examiner determined she was unable to resolve the issues of whether the Veteran's claimed disabilities were the result of his duties as a combat medic in Vietnam without resort to speculation, as the Veteran's claims file was unavailable for review. In a May 2014 addendum opinion, after reviewing the claims file, the examiner stated that none of the claimed conditions of the bilateral knee, bilateral elbows, bilateral ankles, and right hand and fingers were the result of service. Based on her April 2014 examination, the examiner noted the Veteran did not give a history of any of the disabilities begging in service, except for stating that he had injured his knee in service. The examiner noted, however, that the STRs show know treatment for a left knee injury, and the Veteran's separation examination was normal and there were no subjective complaints regarding the knees. The examiner noted the Veteran had a medial meniscal injury of the right knee on the job in May 2003, but went on to state that there were no records contained within the STRs describing any situation where one would expect chronic knee, hand, ankle or elbow problems. The examiner noted that treatment records stated the Veteran broke both of his arms as a child, and that after service, the Veteran was involved in very physical activities, in addition to working on a ranch. The Veteran also submitted lay evidence in support of his claims. In his March 2010 Notice of Disagreement, the Veteran asserted that all of his claimed injuries occurred during service and he now had residual aches and pains from the injuries. He stated that he was certain there would be no record of the injuries in his STRs, noting that as a medic himself, he would not have sought treatment from another medic. He noted one particular injury, which he stated occurred to his right arm, wrist and hand when he was driving into a bunk and underwent a surprise small arms attack one night at base camp, and all hands were involved in the fight. He stated he was occupied treating injuries where he could. Initially, the Board notes the Veteran does not have a diagnosed disability of the right elbow. To the extent that the Veteran is attempting to obtain service connection for right elbow pain, pain alone, without a diagnosed or identifiable underlying malady or condition, does not in and of itself constitute a disability for which service connection may be granted. See Sanchez-Benitez v. West, 13 Vet. App. 282 (1999), appeal dismissed in part, and vacated and remanded in part sub nom. Sanchez-Benitez v. Principi, 259 F.3d 1356 (Fed. Cir. 2001). While the Veteran is competent to report experiencing right elbow pain as the perception of this manifestation comes to him through his senses, and he is credible in this regard, he does not have the medical expertise to attribute his pain to a clinical diagnosis. See Kahana v. Shinseki, 24 Vet. App. 428, 438 (2011). Moreover , after examination and x-ray, the April 2014 examiner determined there was no abnormality of the right elbow and provided no diagnosis. As such, the Board finds there is no present diagnosed right elbow disability, and that service connection is not available for complaints of right elbow pain. Regarding the claims of a left elbow disability, a right hand and finger disability, a bilateral knee disability, and a bilateral ankle disability, the Board finds that the evidence is not in relative equipoise as to whether these disabilities were incurred in, or as a result of, service. The probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, his or her knowledge and skill in analyzing the data, and his or her medical conclusion. As is true with any piece of evidence, the credibility and weight to be attached to these opinions are within the province of the adjudicator. Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). Whether a physician provides a basis for his or her medical opinion goes to the weight or credibility of the evidence in the adjudication of the merits. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). Other factors for assessing the probative value of a medical opinion are the physician's access to the claims folder and the thoroughness and detail of the opinion. See Prejean v. West, 13 Vet. App. 444, 448-49 (2000). In the case at hand, the April 2014 examiner is a physician who is qualified through education, training, or experience to provide competent medical evidence under 38 C.F.R. § 3.159(a)(1). See Cox v. Nicholson, 20 Vet. App. 563 (2007). The examiner thoroughly reviewed the claims file and interviewed and examined the Veteran. The examiner based her opinion on the lack of evidence of in-service treatment or injuries, as well as the Veteran's assertions indicating lack of symptoms or treatment for all claimed injuries, except his left knee, for many years following service. However, regarding the left knee, the Veteran never described the incident in which he claims he injured his left knee, and the examiner noted the Veteran did not have knee complaints on separation from service, or many years thereafter. In this case, the April 2014 examiner's opinion contains an analysis that is supported by the record and clearly articulates the rationale for concluding that the Veteran's claimed disabilities are not related to service. Therefore, it is entitled to great probative weight. The Board notes the June 2012 treatment record from Dr. T.G. describing the Veteran's right knee disability, which states "As the result of the progression of these conditions that have occurred as a result of the service related conditions/injuries, the Veteran has developed increased disability." The Board does not find this opinion to be highly probative as to whether the Veteran's right knee disability is related to service. The opinion does not provide description of any in-service injury to which the Veteran's right knee disability is related, and provides no rationale for why the current condition is the result of any such injury. "[M]ost of the probative value of a medical opinion comes from its reasoning. Neither a VA medical examination report nor a private medical opinion is entitled to any weight in a service-connection or rating context if it contains only data and conclusions." Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). As such, the opinion is not entitled great probative weight. The Board notes that the only other favorable opinion of record comes from the Veteran himself, who believes his bilateral knee, left elbow, bilateral ankle, and right hand and finger disabilities are related to service. The Board recognizes that there are instances in which lay testimony can provide probative evidence in medical matters. A lay person may be competent to offer testimony on certain medical matters, such as describing symptoms observable to the naked eye, or even diagnosing simple conditions such as a dislocated shoulder. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (explaining in footnote 4 that a veteran is competent to provide a diagnosis of a simple condition such as a broken leg, but not competent to provide evidence as to more complex medical questions). However, as a lay person, the Veteran is not competent to offer testimony on the complex medical question of the etiology of his old bilateral ankle sprains, mild left elbow strain, left knee degenerative joint disease status post total knee replacement, diagnosed right knee focal calcification of the medial joint line, and degenerative joint disease of the right hand. Moreover, the Veteran has provided only conclusory statements about the relationship of his disabilities to service, stating generally that he suffered injuries during service, but providing no description of the injuries, how they were incurred, or how they were treated. As such, the Board finds the Veteran is not entitled to service connection on a direct basis for the claimed conditions. The Veteran is also not entitled to service connection for his bilateral knee and right hand and finger disabilities on a presumptive basis because the disabilities initially manifested many years after his separation from service. Service connection for arthritis will rebuttably be presumed if it is manifest to a compensable degree within one year following active service. See 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 2014); 38 C.F.R. §§ 3.307, 3.309(a). Alternatively, a nexus to service will be presumed where there is continuity of symptomatology since service. See Walker v. Shinseki, 708 F.3d 1331, 1338-40 (Fed. Cir. 2013) (holding that continuity of symptomatology is an evidentiary tool to aid in the evaluation of whether a chronic disease existed in service or an applicable presumptive period). Though the Veteran has been diagnosed with arthritis of the bilateral knees, and right hand and fingers, the service treatment records do not document any reports of complaints or treatment for the Veteran's knees or right hand. As noted above, the Veteran's November 1967 separation examination indicated normal upper and lower extremities, and the Veteran's accompanying report of medical history listed no complaints of painful joints or a trick or locked knee. This evidence tends to show that the Veteran's bilateral knee and hand disabilities did not have onset during his active service. The record otherwise does not reflect treatment for the knees until 2003, more than 30 years after service, or any treatment for his right hand until February 2010, more than 40 years after service. Notably, the Veteran asserted in his April 2014 VA examination that his knee pain began "years ago, after service," and stated that his right hand and finger pain developed 15 to 20 years prior to the examination, which would indicate onset of symptoms between 1994 and 1999. As the Veteran's bilateral knee and right hand disabilities did not manifest within the year after his separation from service, and he does not assert continuous symptoms since separation, he is not entitled to service connection on a presumptive basis, including continuity of symptomatology. In summary, the Board finds that a preponderance of the evidence is against finding a link between the Veteran's claimed bilateral ankle, bilateral knee, bilateral elbow, and right hand and finger disabilities, and his military service. Here, the most probative evidence shows that the Veteran's claimed disabilities are not etiologically related to his service. The Board has considered the doctrine of reasonable doubt. However, as the preponderance of the evidence is against this claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Accordingly, entitlement to service connection for the claimed disabilities is not warranted on any basis. III. Higher Initial Rating The Veteran was granted service connection for PTSD in a January 2010 rating decision, with a 50 percent rating effective as of August 20, 2009. In an October 2014 rating decision, the Veteran was awarded a temporary evaluation of 100 percent, effective August 11, 2014 to September 30, 2014; the Veteran's 50 percent evaluation was reinstated, effective October 1, 2014. For the reasons that follow, the Board concludes that an initial rating in excess of 50 percent prior to August 11, 2014 or since October 1, 2014, is not warranted. Disability evaluations are determined by application of the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. When a question arises as to which of two ratings under a particular diagnostic code, the higher rating is assigned if the disability more nearly approximates the criteria for the higher rating. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). When entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, in Fenderson, the Court noted an important distinction between appeals involving a Veteran's disagreement with the initial rating assigned at the time a disability is service-connected. When the question is the propriety of the initial rating assigned, evaluation of the medical evidence since the effective date of the grant of service connection to consider the appropriateness of the "staged ratings" (i.e., assignment of different ratings for distinct periods of time, based on the facts found) is required. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). The Veteran's PTSD has been rated under Diagnostic Code 9411. The Board notes that psychiatric disabilities other than eating disorders are rated pursuant to the criteria for the General Rating Formula. See 38 C.F.R. § 4.130. Under the formula, the criteria for a 50 percent rating are: Occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. The criteria for a 70 percent rating are: Occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near- continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting; inability to establish and maintain effective relationships.) The criteria for a 100 percent rating are: Total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, Diagnostic Code 9411. The list of symptoms under the general rating formula are meant to be examples of symptoms that would warrant the evaluation, but are not meant to be exhaustive, and the Board need not find all or even some of the symptoms to award a specific evaluation. If the evidence shows that the veteran suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the diagnostic code, the appropriate equivalent rating will be assigned. Mauerhan, 16 Vet. App. at 442-43. The United States Court of Appeals for the Federal Circuit ("Federal Circuit") has embraced the Mauerhan Court's interpretation of the criteria for rating psychiatric disabilities. Sellers v. Principi, 372 F.3d 1318, 1326 (Fed. Cir. 2004). Although the Veteran's symptomatology is the primary consideration, the veteran's level of impairment must be in "most areas" applicable to the relevant percentage rating criteria. Vazquez-Claudio v. Shinseki, 713 F.3d 112 (2013). When it is not possible to separate the effects of the service-connected disability from a nonservice-connected condition, such signs and symptoms must be attributed to the service-connected disability. 38 C.F.R. § 3.102; Mittleider v. West, 11 Vet. App. 181, 182 (1998) (per curiam). Psychiatric examinations frequently include assignment of a Global Assessment of Functioning (GAF) score. According to the Fourth Edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) (adopted by VA at 38 C.F.R. §§ 4.125 and 4.126 (2013), a GAF is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental health illness. See, e.g., Richard v. Brown, 9 Vet. App. 266, 267 (1996); Carpenter v. Brown, 8 Vet. App. 240, 242 (1995). A GAF score in the range of "31 to 40" represents "[s]ome impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) OR major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up younger children, is defiant at home, and is failing at school). Id. A GAF score in the range of "41 to 50" illustrates serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning. A GAF Score in the range of "51 to 60" represents more moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). Id. However, the GAF score assigned in a case, like an examiner assessment of the severity of the condition, is not dispositive of the evaluation at issue; rather the GAF score must be considered in light of the actual symptoms of the Veteran's disorder, which provide the primary basis for the rating assigned. See 38 C.F.R. § 4.126(a). In early October 2009, the Veteran received psychiatric treatment at a VA clinic. The report noted that the Veteran first had problems with PTSD symptoms when he retired in 2007, including increased feelings of jumpiness and nervousness, and difficulty sleeping. He reported that after being prescribed citalopram, his symptoms became worse. He stated he coped with his symptoms usually by working early, working late, and avoiding everything. He endorsed symptoms of depression most days, variable concentration, poor sleep, okay appetite, feelings of worthlessness and hopelessness, anhedonia, occasional suicidal ideation but without intent or homicidal ideation, visual hallucinations to include shadows, and feelings of guilt. He also reported nightmares that wake him, flashbacks that occur 2 to 3 times a month triggered by damp scents and helicopters, irritability, intrusive memories, hypervigilance, hyperstartle response, and avoidance of discussions or movies about war, crowds, stores and hospitals. The examiner noted a diagnosis of PTSD and depression, not otherwise specified and assigned a GAF score of 50. Also in October 2009, the Veteran underwent a VA examination for his PTSD. The Veteran reported he was married, but had a rocky or stormy marriage. He noted he had a good relationship with his children. He reported that he did not socialize with a lot of people, but had a couple of close friends, and stated that due to the small size of the town he lived in, he did not quite a few people. He stated that if there was something of interest to him, he would go out but normally did not seek outside activities. He reported that he used to hunt often, and still hunts, but to a lesser extent. He noted he had become involved in gold panning, and enjoyed being in the wilderness by himself. The Veteran denied a history of suicide attempts or violence, but endorsed suicidal ideation without plan or intent. He reported that most of the time his mood was pretty good, but since his retirement, he experienced recurrent bouts of depression because he had more time to think about things. He endorsed nightmares that awakened him, also noting he was a light sleeper and startled easily. He reported that when he was awakened, he got up to check the house and rarely felt rested when he woke. He denied panic attacks or homicidal ideation, and had no memory impairment, but endorsed emotional isolation and frequent feelings of depression and sadness. The examiner assigned a GAF score of 60. VA treatment records dated December 2009 indicate the Veteran still experienced depression some days, but had improved concentration and sleep, and an okay appetite, though he still endorsed occasional suicidal ideation (without plan or intent), visual hallucinations, feelings of guilt, flashbacks 2 to 3 times a month, irritability, intrusive memories, hypervigilance, hyperstartle, and avoidance. Additional records from that month indicate the Veteran was eagerly awaiting the birth of his grandson, and had worked a lot recently, which made him appreciative of the opportunity to spend time with people he had known for years. March 2010 VA treatment records indicate that after beginning to take antidepressant medication, the Veteran felt less depressed and had better concentration and better sleep, but felt a little forgetful. In a January 2011 letter, the Veteran described his symptoms of PTSD. He noted difficulty getting things done in a timely manner, and stress concerning deadlines. He noted that completing tasks required great concentration, and he had difficulty carrying on a conversation about a single topic, as his mind wandered. He also endorsed daily flashbacks and nightmares of killing, blood and gore, and smells that interrupted his sleep every night for several hours. He noted that the smell of burning trash could cause a panic attack that lasted all day. He also described a situation in which he cornered and physically threatened a co-worker over a comment the man had made. The Veteran described a feeling of being out of control during this confrontation. He described his aggressive reaction whenever someone startled him, or approached him from behind. He also stated that after returning home from war, he was unable "to get a life", and felt that he had lived his life in a fog, and described lapses where he felt he did not know who or where he was, the identities of his family members, his occupation, and felt disoriented to time. He noted that he had panic attacks on a daily basis, lasting anywhere from a few minutes to a few hours, and thought about suicide constantly though he could not get the "guts to do it." April 2011 VA treatment records reveal the Veteran presented feeling "pretty good except for the URI he has had for about 3 weeks." He noted his wife was recovering well from cancer, and he had a 1 year old grandson that he enjoyed. He denied depression, and endorsed better concentration and better sleep since he began using a CPAP machine. He denied feelings of worthlessness or hopelessness, anhedonia, suicidal or homicidal ideation, audio or visual hallucinations, or guilt. His symptoms were largely unchanged in a November 2011 treatment note, and the examiner noted the Veteran's PTSD and major depressive disorder (MDD) were in partial remission and the Veteran was benefitting from a PTSD group and social network he developed in his community. The examiner assigned a GAF score of 51. The Veteran's symptoms remained unchanged in a September 2012 VA treatment note, and the examiner assigned a GAF score of 50. A September 2012 VA intake assessment indicated the Veteran did not have suicidal thoughts or plan, or a history of suicide attempts. The Veteran endorsed feelings of hopelessness or despair, and the clinician noted that marital distress exacted a high toll on the Veteran. Additional symptoms included difficulty concentrating, learning or recalling formation, significant impairment in social or occupational functioning, excessive fatigue, disturbed sleep, headaches, irritability or aggression, anxiety, depression, apathy of lack of spontaneity, speech difficulties, and changes in personality. The clinician noted the Veteran's manner was suspicious and defensive, his memory function impaired, his affect flat and blunted, and his motor activity tense. The report indicated evidence of disordered thinking. The clinician noted that the Veteran reported fluctuating symptoms of PTSD with outside stressors such as his spouse and work, and reported symptoms of sleep disturbance, nightmares, social isolation, feeling numb, intrusive thoughts, and flashbacks. In a November 2012 VA examination, the examiner determined the Veteran's symptoms were in the moderate range, somewhat worse than those noted on his October 2009 VA examination. The report indicated that reexperiencing symptoms included vivid memories and dreams once a week consistent with combat stressors. The Veteran noted that these dreams evoked self-doubt and regret, reminding him of the lives he was unable to save. He reported panic symptoms once per week in association with the dream. Avoidance symptoms included avoiding discussing his military service (except with other combat veterans), and avoiding hospitals and emergency rooms, as the odors evoked recollections of service. He described a loss of interest in hunting, and felt highly uncomfortable in crowds and public places, though he was able to tolerate restaurants. Hyperarousal symptoms included sleep disturbance; he noted he was able to initiate sleep with a CPAP machine, but had midcycle awakening 2 to 3 times per night, due to dreams once a week or due to sweating. He did, however, obtain adequate sleep, and denied feelings of fatigue. The Veteran reported mild irritability, but denied violence. His memory and concentration were noted as within normal limits on examination of gross cognitive function. The Veteran also endorsed moderate hypervigilance, preferring to sit with his back to a wall, and reported exaggerated startle response to loud noises, the sound of helicopters and others approaching him from behind. Regarding depression, the Veteran denied feeling sad all day, every day and denied crying spells, but stated he worried about the health and wellbeing of family members. He stated he seldom had palpitations or heart pounding, but reported sweating at night due to weekly nightmares. He denied suicidal or homicidal ideation, or auditory or visual hallucinations. The examiner assigned a GAF score of 55. The Veteran noted he was still married, and had 2 sons, with whom he had a good relationship. The Veteran reported that his 3 year old grandson was very much a part of his life, and he and his wife shared in enjoyment of their grandson, but there was otherwise marital tension more than half of the time. The Veteran stated he had fewer than 5 friends, but had close relationships with the veterans groups he attended, and though he no longer hunted, he enjoyed prospecting. He noted he had retired from the highway department with eligibility, and currently worked part time for the highway department depending on weather and the status of his knee. After examination, the examiner determined the Veteran had mild interference with concentration and memory, mild to moderate interference with mood and motivation, mild to moderate interference with social interaction, mild to moderate interference with adaptability and stress tolerance. The examiner concluded the Veteran's symptoms of PTSD did not render him unable to secure and maintain a job. A June 2014 VA psychiatric note indicated the Veteran had PTSD and MDD in partial remission. The Veteran reported continuing problems with his marriage, mainly due to trouble communicating with his wife. The Veteran was not depressed, had better concentration, better sleep with his CPAP machine, no feelings of worthlessness, hopelessness or anhedonia, but endorsed occasional, fleeting suicidal ideation, without plan or intent. The Veteran endorsed nightmares and flashbacks occurring 2 to 3 times a month, variable irritability, intrusive memories, hypervigilance, hyperstartle, avoidance of discussion or movies about war, crowds, stores or hospitals, feelings of numbness and detachment from people. The Veteran had no persistent negative view of the world and found his grandson enjoyable, though he experienced variable inability to have positive feelings. In an August 2014 VA psychology note, the Veteran reported that his symptoms of PTSD were getting worse, and that he felt more irritable and more jumpy. When asked directly, the Veteran flatly denied suicidal and homicidal ideation, intent, or plan and further denied a history of suicide attempts. He endorsed intrusive thoughts every day, nightmares twice a month, reported flashbacks, unsteadiness and lightheadedness, and avoidance of traumatic thoughts. The Veteran denied an inability to remember important aspects of the trauma, but did report cognitive distortions, saying civilians had no idea what he had experienced, and also reported guilt and persistent feelings of sadness. He also reported a flattened mood, and difficulty experiencing positive emotions with the exception of spending time with his grandson. He also noted feeling detached from others, a loss of interest in activities he once found enjoyable such as hunting or horseback riding (though he did note he went gold prospecting, alone or with another veteran, and put up hay in the summertime), and was hypervigilant, had exaggerated startle response, difficulty concentrating, irritability, moderate depression, and saw movements out of the corners of his eye that turned out to be shadows. He noted a rocky relationship with his wife, but reported a good relationship with his children. In a letter dated October 2014, the Veteran's wife submitted a statement reporting that the Veteran had always been polite but distant, as far as allowing her to get close to him emotionally, and had become increasingly distant over the years. During the period on appeal, the Board finds the Veteran's PTSD symptoms were manifested by occupational and social impairment, with reduced reliability and productivity, indicative of a 50 percent disability rating. The Veteran's symptoms generally included: nightmares, irritability, anxiety, jumpiness and nervousness, difficulty sleeping (due to sleep apnea and nightmares), depression, flashbacks 2 or 3 times a month, marital difficulties and feelings of guilt. The Veteran also reported leaving his fulltime job, but noted this was due to retirement, and added that he still worked part time at the same agency; the November 2012 examiner also determined PTSD did not render the Veteran unable to secure and maintain a job. The Veteran also had symptoms of intrusive memories, blunted affect, hypervigilance, hyperstartle response, and avoidance of discussions or movies about war, crowds, stores and hospitals. These symptoms are consistent with and similar to many of those contemplated by the currently assigned 50 percent rating, such as panic attacks more than once a week, disturbances of motivation and mood, such as panic attacks more than once a week, difficulty in establishing and impaired abstract thinking, and flattened affect. The record evidence, however, does not reflect a higher level of impairment as contemplated by the criteria for 70 percent rating. During the period on appeal, the Veteran's speech was normal, his insight and judgment were intact, and his thought processes were logical and relevant. The Veteran had a "rocky" relationship with his wife, but remained married, and maintained a good relationship with his children, and enjoyed spending time with his grandson. Though he no longer hunted, the Veteran engaged in activities like stacking hay in the summer, gold prospecting with other veterans. He also joined a veterans PTSD group, which he found helpful, and worked occasionally at his old job, where he enjoyed spending time with people he knew. The Veteran endorsed variable degrees of depression, reporting in October 2009, January 2011, and September 2012 that he felt depressed and thought often of suicide (though he had never attempted suicide and had no plan or intent to commit suicide), but stating in March 2010, April 2011 and June 2014 and that he felt pretty good and had no suicidal ideation, prompting VA treatment providers to note his PTSD and MDD were in partial remission. The September 2012 VA intake assessment noted the Veteran endorsed feelings of hopelessness or despair, and his manner was suspicious and defensive, his memory function impaired, his affect flat and blunted. However, the November 2012 examination noted the Veteran's memory and concentration were noted as within normal limits on examination of gross cognitive function, and denied feeling sad all day, every day or crying spells. Though the Veteran reported variable symptoms of depression, and because the 70 percent level contemplates a deficiency in "mood" among other areas, does not mean his PTSD rises to the 70 percent level. Rather, the Board notes that in regards to the Veteran's mood, his symptoms overall are more consistent with those associated with a 50 percent disability rating. The Veteran's does not have near-continuous anxiety or panic that would be more consistent with a 70 percent rating. Rather, his mood varied from good to anxious to depressed as shown over the course of his VA treatment records. The Board notes the assigned GAF scores during the period on appeal ranging between 50 and 60. A GAF score of 50 indicates serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning, while the GAF scores of 51 to 60 represent more moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). The Board finds that the Veteran's GAF scores support a conclusion that the Veteran had occupational and social impairment with reduced reliability and productivity, but do not show that the Veteran has occupational and social impairment with deficiencies in most areas such as family relations, judgment and thinking, for a 70 percent disability rating, and likewise does not indicate total occupational and social impairment, for a 100 percent disability rating. Again, the Veteran's symptoms, including nightmares, feeling depressed at times, anxiety, marital troubles, and irritability do not rise to the level of severity, frequency or duration that cause impairment of social and occupational functioning with deficiencies in most of the areas such as those enumerated in the regulation. The preponderance of the evidence of record is against a finding that the Veteran's PTSD has resulted in total occupational and social impairment at any time. The Veteran has remained married, has a good relationship with his children, and has a few close friends. The Veteran also has activities, such as hay stacking and gold prospecting that he enjoys, and occasionally worked seasonally part time at his old job. Further, the November 2012 examiner also determined PTSD did not render the Veteran unable to secure and maintain a job. None of the treatment records indicate the Veteran was not alert or oriented at examination, or that he was financially unstable. There is no medical determination that the Veteran's PTSD symptoms resulted in total occupational and social impairment, and the reported symptoms do not otherwise suggest this is the case. Given that the record evidence does not indicate a level of impairment to support a determination of total occupational and social impairment at any time, a 100 percent schedular rating is not warranted. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Consistent with the facts found, the rating may be higher or lower for segments of the time under review on appeal, i.e., the rating may be "staged." Fenderson v. West, 12 Vet. App. 119 (1999); see also Hart v. Mansfield, 21 Vet. App. 505 (2007). The Board has considered the possibility of staged ratings. The Board, however, concludes that the criteria for a rating in excess of 50 percent have at no time been met. Accordingly, staged ratings are inapplicable. See id. The Board has also considered whether a referral for extraschedular rating is warranted. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). Initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule; therefore, the assigned schedular evaluation is adequate, and no referral is required. See VAOPGCPREC 6-96; see also Fisher v. Principi, 4 Vet. App. 57, 60 (1993). The schedular evaluation for the Veteran's PTSD disability is not inadequate. The Veteran has complained of symptoms such as nightmares, anxiety, sleep disturbance, irritability, avoidance of crowds or war related conversations or movies, hypervigilance, exaggerated startle response, and depression. These symptoms are all considered by the rating criteria. The Veteran merely disagrees with the assigned evaluation for his level of impairment. In other words, he does not have any symptoms from his service-connected disorder that are unusual or are different from those contemplated by the schedular criteria. The available schedular evaluations reasonably describe the service-connected disorder; thus, the schedular evaluations are adequate to rate the Veteran's disorder. The Board need not determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms" such as "marked interference with employment" and "frequent periods of hospitalization." See Thun, 22 Vet. App. at 115. Referral for extraschedular consideration is not warranted. See VAOPGCPREC 6-96. As such, the Board finds that the preponderance of the evidence is against the Veteran's increased rating claim. Consequently, the benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. ORDER Entitlement to an initial evaluation in excess of 50 percent for PTSD is denied. Entitlement to service connection for a left knee disability, to include degenerative joint disease is denied. Entitlement to service connection for a right knee disability, to include focal calcification of the medial joint line is denied. Entitlement to service connection for a right hand and finger disability, to include osteoarthritis is denied. Entitlement to service connection for bilateral ankle sprains is denied. Entitlement to service connection for a bilateral elbow disability is denied. REMAND OSA The Veteran claims he is entitled to service connection for OSA, which he claimed is a result of his PTSD. The Board finds additional development is required prior to adjudication of the claim. In a September 2012 VA treatment record, the examiner noted that the Veteran was on a CPAP machine, and indicated an OSA screen returned positive results. A later August 2014 treatment note indicates the Veteran underwent a sleep apnea consult on January 14, 2011, however, these results are not present within the claims file. In order to satisfy its duty to assist, the VA must make reasonable efforts to assist the Veteran in securing evidence necessary to substantiate his claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). The AOJ/AMC should request copies of any outstanding VA treatment records relating to the Veteran's treatment for a sleep disorder, from all VA Medical Centers at which the Veteran was treated, including the Southern Arizona VA Health Care System, New Mexico VA Health Care System, and Farmington Veteran Center, dated January 2011. Further, a VA examination and opinion are needed. The duty to assist includes providing a medical examination or obtaining a medical opinion when such is necessary to make a decision on the claim, as defined by law. The case of McLendon v. Nicholson, 20 Vet. App. 79 (2006), held that an examination is required when (1) there is evidence of a current disability, (2) evidence establishing an "in-service event, injury or disease," or a disease manifested in accordance with presumptive service connection regulations occurred which would support incurrence or aggravation, (3) an indication that the current disability may be related to the in-service event, and (4) insufficient evidence to decide the case. The evidence suggests the Veteran has a diagnosis of OSA, which the Veteran has related to service, stating that he had difficulty sleeping ever since his return from Vietnam and that the problem persisted. The Veteran associated his OSA with his PTSD, stating that he woke frequently at night due to nightmares and was unable to fall back asleep. A VA examination was not conducted to determine whether the Veteran's apparent sleep disorder is directly related to service, or related to or aggravated by his service-connected PTSD. For the foregoing reasons, the Board finds that a VA examination should be issued concerning the Veteran's claim for service connection for OSA. The examiner should offer an opinion as to whether the Veteran has a current diagnosis of OSA, and if so, whether it is directly related to service, and alternately, whether it is the result of or has been aggravated (permanently worsened beyond normal progress of the disorder) by his service-connected PTSD. All lay and medical evidence should be considered, to include the Veteran's assertions that his sleeping problems persisted since service. TDIU The Veteran contends that the combined effect of the service-connected disabilities render him unemployable. Throughout the period on appeal the Veteran has been retired, though he noted occasional seasonal work depending on how he felt. The Veteran is presently service-connected for PTSD, rated as 50 percent disabling, left wrist osteoarthritis, rated as 10 percent disabling, and bilateral hearing loss, rated as 0 percent disabling. His combined service-connected rating for these disabilities is 60 percent; and he does not meet the minimum schedule requirements for a TDIU under 38 C.F.R. § 4.16(a) (2014). As indicated above, the Board is remanding the issue concerning OSA. As such, the resolution of this service connection issue could materially affect the Veteran's claim for a TDIU due to the combined effect of all of his service-connected disabilities, and whether the schedular requirements of 38 C.F.R. § 4.16(a) may be met in this case. Under these particular circumstances, the Board finds that these issues are inextricably intertwined, and thus a decision at this time with respect to the TDIU claim would be premature. See Henderson v. West, 12 Vet. App. 11, 20 (1998); Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). Accordingly, the Board's appellate consideration of the TDIU claim is deferred pending the outcome on the matters concerning service connection for OSA. Accordingly, the case is REMANDED for the following action: 1. The AOJ/AMC must obtain any outstanding VA treatment records from the Southern Arizona VA Health Care System, New Mexico VA Health Care System, and Farmington Veteran Center dated in January 2011. Any response received should be recorded in the Veteran's VA claims file. 2. The AOJ/AMC should also contact the Veteran to determine whether he has received any additional private treatment for his OSA, and if so, take steps necessary to obtain these records. Any response received should be recorded in the Veteran's VA claims file. 3. Thereafter, schedule a VA examination to address the Veteran's claimed OSA. All pertinent evidence, including any relevant information in Virtual VA and VBMS, should be made available to the examiner for review, and such review should be noted in the opinion report. All necessary evaluations, studies, and tests deemed appropriate by the examiner should be accomplished. a. Does the Veteran have a current diagnosis of OSA? b. If the answer to (a) is "yes," is it at least as likely as not (a 50 percent or greater probability) that the current diagnosis of OSA is causally related to military service, to include the Veteran's lay assertions that his sleep disturbances have persisted since service? c. If the answer to (a) is "yes," and the answer to (b) is "no," is it at least as likely as not (a 50 percent or greater probability) that the current diagnosis of OSA is proximately due to or the result of the Veteran's service-connected PTSD? d. If the answer to (a) is "yes," and the answer to (c) is "no," is it at least as likely as not (a 50 percent or greater probability) that the Veteran's service-connected PTSD aggravated the OSA? In this special context, "aggravation" has occurred when it has been medically determined that the claimed condition has undergone an identifiable permanent increase in severity that was proximately due to or the result of PTSD. If aggravation by a service-connected disability is found, then the examiner should quantify the degree of such aggravation, if possible. The examiner should explain the medical basis for the conclusion reached. 4. Thereafter, review the claims file to ensure that all of the foregoing development is completed, to the extent possible, and then re-adjudicate the Veteran's claim of entitlement to service connection and entitlement to a TDIU rating, including consideration of whether the requirements for referral to the Director and Compensation and Pension Service have been invoked under 38 C.F.R. § 4.16(b). If the benefits sought on appeal remains denied, the Veteran and his representative must be provided with a Supplemental Statement of the Case. An appropriate period of time should be allowed for response. The appellant has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ______________________________________________ DEBORAH W. SINGLETON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs